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March 26 2012

Five tough lessons I had to learn about health care

Working in the health care space has forced me to give up many hopes and expectations that I had a few years ago. Forgive me for being cynical (it's an easy feeling to have following the country's largest health IT conference, as I reported a month ago), and indeed some positive trends do step in to shore up hope. I'll go over the redeeming factors after listing the five tough lessons.

1. The health care field will not adopt a Silicon Valley mentality

Wild, willful, ego-driven experimentation--a zeal for throwing money after intriguing ideas with minimal business plans--has seemed work for the computer field, and much of the world is trying to adopt a "California optimism." A lot of venture capitalists and technology fans deem this attitude the way to redeem health care from its morass of expensive solutions that don't lead to cures. But it won't happen, at least not the way they paint it.

Health care is one of the most regulated fields in public life, and we want it that way. From the moment we walk into a health facility, we expect the staff to be following rigorous policies to avoid infections. (They don't, but we expect them to.) And not just anybody can set up a shield outside the door and call themselves a doctor. In the nineteenth century it was easier, but we don't consider that a golden age of medicine.

Instead, doctors go through some of the longest and most demanding training that exists in the world today. And even after they're licensed, they have to regularly sign up for continuing education to keep practicing. Other fields in medicine are similar. The whole industry is constrained by endless requirements that make sure the insiders remain in their seats and no "disruptive technologies" raise surprises. Just ask a legal expert about the complex mesh of Federal and state regulations that a health care provider has to navigate to protect patient privacy--and you do want your medical records to be private, don't you?--before you rave about the Silicon Valley mentality. Also read the O'Reilly book by Fred Trotter and David Uhlman about the health care system as it really is.

Nor can patients change treatments with the ease of closing down a Facebook account. Once a patient has established a trust relationship with a doctor and obtained a treatment plan, he or she won't say, "I think I'll go down the road to another center that charges $100 less for this procedure." And indeed, health reform doesn't prosper from breaking down treatments into individual chunks. Progress lies in the opposite direction: the redemptive potential of long-term relationships.

2. Regulations can't force change

I am very impressed with the HITECH act (a product of the American Recovery and Reinvestment Act, more than the Affordable Care Act) that set modern health reform in motion, as well as the efforts of the Department of Health and Human Services to push institutions forward. But change in health care, like education, boils down to the interaction in a room between a professional and a client. Just as lesson plans and tests can't ensure that a teacher inspires a child to learn, regulations can't keep a doctor from ordering an unnecessary test to placate an anxious patient.

We can offer clinical decision support to suggest what has worked for other patients, but we can't keep a patient from asking for a expensive procedure that has a 10% chance of making him better (and a 20% chance of making him worse), nor can we make the moral decision about what treatment to pursue, for the patient or the doctor. Each patient is different, anyway. No one wants to be a statistic.

3. The insurance companies are not the locus of cost and treatment problems

Health insurers are a favorite target of hatred by Americans, exemplified by Michael Moore's 2007 movie Sicko and more surprisingly in the 1997 romantic comedy As Good as it Gets, where I saw an audience applaud as Helen Hunt delivered a rant against health maintenance organizations. A lot of activists, looking at other countries, declare that our problems would be solved (well, would improve a lot) if we got private insurers out of the picture.

Sure, there's a lot of waste in the current insurance system, which deliberately stretches out the task of payment and makes it take up the days of full-time staff in each doctor's office. But that's not the cause of the main problems in either costs or treatment failures. The problems lie with the beloved treatment staff. We can respect their hard work and the lives they save, but we don't have to respect them for releasing patients from hospitals without adequate follow-up, or for ordering unnecessary radiation that creates harm for patients, or for the preventable errors that still (after years of publicity) kill 90,000 to 100,000 patients a year.

4. Doctors don't want to be care managers

The premise of health reform is to integrate patients into a larger plan for managing a population. A doctor is supposed to manage a case load and keep his or her pipeline full while not spending too much. The thrust of various remuneration schemes, old and new, that go beyond fee for service (capitation, global payment systems) is to reward a doctor for handling patients of a particular type (for instance, elderly people with hypertension) at a particular cost. But doctors aren't trained for this. They want to fix the immediate, presenting complaint and send the patient home until they're needed again. Some think longitudinally, and diligently try to treat the whole person rather than a symptom. But managing their treatment options as a finite resource is just not in their skill set.

The United Kingdom--host of one of the world's great national care systems--is about to launch a bold new program where doctors have to do case management. The doctors are rebelling. If this is the future of medicine, we'll have to find new medical personnel to do it.

5. Patients don't want to be care managers

Now that the medical field has responded superbly to acute health problems, we are left with long-term problems that require lifestyle and environmental changes. The patient is even more important than the doctor in these modern ills. But the patients who cost the most and need to make the most far-ranging changes are demonstrating an immunity to good advice. They didn't get emphysema or Type 2 diabetes by acting healthily in the first place, and they aren't about to climb out of their condition voluntarily either.

You know what the problem with chronic disease is? Its worst effects are not likely to show up early in life when lifestyle change could make the most difference. (Serious pain can come quickly from some chronic illnesses, such as asthma and Crohn's disease, but these are also hard to fix through lifestyle changes, if by "lifestyle change" you mean breathing clean air.) The changes a patient would have to make to prevent smoking-related lung disease or obesity-related problems would require a piercing re-evaluation of his course of life, which few can do. And incidentally, they are neither motivated nor trained to store their own personal health records.

Hope for the future

Despite the disappointments I've undergone in learning about health care, I expect the system to change for the better. It has to, because the public just won't tolerate more precipitous price hikes and sub-standard care.

There's a paucity of citations in my five lessons because they tend not to be laid out bluntly in research or opinion pieces; for the most part, they emerged gradually over many hallway conversations I had. Each of the five lessons contain a "not," indicating that they attack common myths. Myths (in the traditional sense) in fact are very useful constructs, because they organize the understanding of the world that societies have trouble articulating in other ways. We can realize that myths are historically inaccurate while finding positive steps forward in them.

The Silicon Valley mentality will have some effect through new devices and mobile phone apps that promote healthy activity. They can help with everything from basic compliance--remembering to take prescribed meds--to promoting fitness crazes and keeping disabled people in their homes. Lectures given once in a year in the doctor's office don't lead to deep personal change, but having a helper nearby (even a digital one) can impel a person to act better, hour by hour and day by day. This has been proven by psychologists over and over: motivation is best delivered in small, regular doses (a theme found in my posting from HIMSS).

Because the most needy patients are often the most recalcitrant ones, personal responsibility has to intersect with professional guidance. A doctor has to work the patient, and other staff can shore up good habits as well. This requires the doctors' electronic record systems to accept patient data, such as weight and mood. Projects such as Indivo X support these enhancements, which traditional electronic record systems are ill-prepared for.

Although doctors eschew case management, there are plenty of other professionals who can help them with it, and forming Accountable Care Organizations gives the treatment staff access to such help. Tons of potential savings lie in the data that clinicians could collect and aggregate. Still more data is being loaded by the federal government regularly at Health.Data.Gov. ACOs and other large institutions can hire people who love to crunch big data (if such staff can be found, because they're in extremely high demand now in almost every industry) to create systems that slide seamlessly into clinical decision support and provide guidelines for better treatment, as well as handle the clinic's logistics better. So what we need to do is train a lot more experts in big data to understand the health care field and crunch its numbers.

Change will be disruptive, and will not be welcomed with open arms. Those who want a better system need to look at the areas where change is most likely to make a difference.

February 05 2011

Report from Massachusetts Health IT forum

To talk of a "revolution" in health care would be demeaning to the
thousands of people staking their lives on real revolutions right now
in various countries, but there is no doubt that the conflation of
out-of-control health care costs, fancy new technologies, and various
government mandates (not only from the US government, but from many
states including Massachusetts) have forced doctors, vendors, and
other people in the heath care field to scramble and order changes
throughout their organizations. A couple hundred of these people came
to the "Tools
for Meaningful and Accountable Care" conference
held yesterday by
the Massachusetts Health Data
Consortium
.

I didn't interview many participants (the ones I talked to were very
happy with the presentations) but I wonder whether all of them got
what they came for. They may well be haggling over questions such as
"How many prescriptions do we need to order online in 2011 in order to
qualify for the first stage of Meaningful Use booty?" or "How do I get
an image from the radiologist down the street while satisfying HIPAA
privacy regulations?" What they got, however, was a broad look at the
needs of health care and a set of projections by various speakers that
congealed into what I find to be a coherent vision for health care in
the future.

And I think the communication of this vision is important. Costs will
continue to rise and reform will fail if doctors, vendors, and IT
staffs simply race to meet each stage of regulations and act in an ad
hoc manner without an overall coordination of effort. Just how broad
this coordination of effort must be--we're not talking here just about
gathering an entire hospital around a program, or even a whole
consortium such as Partners HealthCare, the biggest Massachusetts
provider--will come out during this article.

Capitation versus Clinical Effectiveness Research

One of the big changes in the Massachusetts health care scene went
oddly unmentioned during the whole day of talks. I'm referring to the
href="http://www.boston.com/business/healthcare/articles/2011/01/23/blue_cross_ceo_says_providers_must_control_health_care_costs_or_else/">dictat
from Blue Cross/Blue Shield of Massachusetts announcing that they
will change from fee-for-service to a "global payment plan." This
mirrors recent plans from the state government to pressure the health
care insurers and providers to pay for outcome rather than for
individual procedures. But imposed on the current delivery system,
such a "global payment plan" is just a repackaging of old-fashioned
capitation.

Nobody seems to want to admit this, just as people are reluctant to
announce the return of "managed care" and prefer to assign the new,
as-yet untainted term "accountable care organization." It was up to
the CEO of a leading ACO--Dr. Craig Samitt of Dean Healthcare in
Wisconsin--to display a slide in his keynote with an equal sign
connecting "managed care" and "accountable care organization." He said
this moment is our chance to do managed care right.

(It's also sobering that in Massachusetts, world center for health
care, the two organizations singled out at this conference for their
achievements in bringing to life the potential in health care IT both
lay outside the state: Wisconsin's Dean Healthcare and central Texas's
Scott & White Health Plan. Furthermore, the individuals who
traveled here to describe their work had both spent long careers in
Massachusetts health care organizations before traveling elsewhere to
lead these advances.)

Payments for outcome and ACOs can work: they can lower costs while
simultaneously improving health care. But by themselves they're like a
meringue fashioned out of only sugar and cornstarch. The egg that will
make them work is clinical effectiveness research, a topic excellently
covered in talks by two doctors, Harold C. Sox and Michael Fischer.

CER is a medical application of the quality control routinely done in
other industries; it perhaps has its origin in time-and-motion
studies. It asks tough questions such as why one surgeon has far
greater success on the same patient population as another--not in
order to reward or punish, but to convey the best practices from one
clinic and region to another. CER should overcome the enormous
disparities that we all know exist between doctors, between hospitals,
between patient populations (such as differences in outcome by race)
and between different parts of the country.

Dr. Sox pointed out that CER was being tried as early as the 1960s,
but took a great leap in the mid-1990s and continues to make advances
despite such cynical political pot-shots as raising the fear of death
panels. (I highly recommend href="http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande">Atul
Gawande's New Yorker article for a sweeping overview of the real
purpose and effect of end-of-life decisions.) CER is now formalized by
the Federal Government in several initiatives that are not likely to
go away.

Dr. Fischer said that CER required big changes in education and in
how results are delivered. Crude impressions like "death panels" have
to be fought with better outreach to the public. Continuing medical
education (which has impolitely referred to as "broken") needs to be
more hands-on and to demonstrate that doctors understand the material
they've been given. And EMRs have to become much more sophisticated at
delivering information.

Currently, doctors using EMRs are pelted with notorious "alerts" that
resemble the warnings web browsers give all of us when we visit web
sites with outdated security certificates. Most doctors treat the
alerts like web users treat the security dialog boxes--they ignore
them and click through. And that's because they're just too darned
many alerts. Every medication has some potential impact on something
(a rare food allergy, for instance) and the computer systems can't
figure out what doctors really need to know. Furthermore, if a system
displays an alert and the patient experiences a problem later, the
doctor's liability is increased. If a doctor dismisses an alert, he or
she had better type in a reason for doing so.

Making CER work will require vendors to design more flexible systems,
and the IT staff at each institution to choose the alerts that can
actually affect medical decisions. Some of the enforcement can also be
spread around: nurses and other staff can be involved in CER.

All Together Now

The value that comes from aggregating results of procedures and
treatments raises several questions. One is the effects on patient
privacy, because it's well-known that anonymized data can often be
de-anonymized, and we're talking here of widely shared data being
crunched by dozens or hundreds of organizations. (I'm on the planning
committee for an href="http://www.utexas.edu/lbj/healthprivacy">upcoming conference on
health data privacy.) But a deeper question concerns the ability
of many forces to work together to make change.

A small medical practice can't internally collect enough data to
determine statistically what works and what doesn't. Unless someone
coordinates these small practices, they will fall behind and lose both
money and patients. But even a large institution has limited access to
data. Michael Lee, a director at the fairly large Atrius Health
group, said they wished they could see data on their patients after
they move on to other institutions. Better care and lower costs will
require massive coordination across the country.

The Direct
Project
at Health and Human Services, which reached a major
milestone last week with the announcement of some successful data
transfers, should become a platform for such exchange and coordination
(and they're taking privacy quite seriously). But it's just a
platform--echoing a point made by Joel Vengco of GE--whose value
emerges only through the proper encoding, exchange, and interpretation
of data, followed ultimately by the dissemination of results and their
use by providers. (Whew.)

This is perhaps why Micky Tripathi, president of the Massachusetts
eHealth Collective, stressed that doctors have to move from just
entering data into their EHRs to entering accurate data, and using
structures that allow it to be parsed and crunched. It was also
pointed out that many of the requirements for receiving meaningful use
payments depend on multiple institutions: specialists, labs,
pharmacies, and other institutions the doctor deals with have to be
set up to send and receive the communications for which the government
rewards the individual doctor.

It used to be that doctors would practice and health care researchers
would do research (with some overlap, of course, at teaching hospitals
and major research centers). Practice and research are now
intertwining and perhaps merging.

All these ways in which health reform becomes a group effort show why
a high-level vision is important. And someone at the top must firmly
hold on to this vision. That's why I had a second surprise yesterday
at a news item that went unmentioned: the upcoming href="http://www.healthcareitnews.com/news/blumenthal-leave-onc">departure
of David Blumenthal, National Coordinator for Health Information
Technology. I trust that the ONC is suffused with enough smart
people holding firm to their goals for it to continue to make change.
If Blumenthal's departure slows down implementation, though, maybe it
will give us a welcome breathing space to re-evaluate our tools and
what we need them to accomplish.

Too expensive, too hard to use, and too disruptive to workflow

That was the three-sided accusation delivered to vendors of EHRs by
Dr. Marylou Buyse, the chief medical director of Scott & White
Health Plan, who spoke at yesterday's conference and won an
achievement award there. Nobody blinked when she delivered the
judgment, and indeed it's one I've heard repeatedly. Dr. Buyse should
have added that their proprietary formats and imprecise
implementations of standards throw up enormous barriers to the data
exchange required for meaningful use, as I discussed in a href="http://radar.oreilly.com/2010/03/report-from-himms-health-it-co-1.html">report
from last year's HIMSS conference.

Few speakers picked up this theme, perhaps because many vendors were
present, and perhaps because the speakers figured we had to soldier on
with whatever we had. My third surprise of the day, regarding
unmentioned news, was the alarming href="http://www.whitehouse.gov/sites/default/files/microsites/ostp/pcast-health-it-report.pdf">
report by the President’s Council of Advisors on Science and
Technology expressing concern about the ability of current EHRs to
carry out the basic data exchanges required for improvements in health
care.

Maybe health care in the US is so far behind the digital age that any
upgrade would produce benefits. Paul Grabscheid of InterSystems
reminded the audience of a recent study showing that two-thirds of
doctors still use fax machines to send medical records out, and the
next biggest medium in use is snail mail. Adoption of EHRs is rising
in this country (it may be up to 20%, depending on how it's counted)
but is still extremely inadequate. Nevertheless, most observers don't
call for moving full-speed ahead with existing computer systems and
workflows. Before making investments, it's important to be smart.

Better standards, as the PCAST report called for, are important, and open source systems would address interoperability. (I feel it justified to insert a plug here for the health care track at O'Reilly's Open Source convention. But most of all, we've all got to work together. Spent forces with nothing new to offer must be pushed out of the way, while the vast majority of people have to set aside maneuvers for short-term advantage and focus on a common goal. To return to the stirring words of keynoter Dr. Samitt, insurers and providers (and he could have added patients and politicians) have to "work together to drive change."

Maybe that's the key to any revolution.

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